Healthcare Provider Details

I. General information

NPI: 1154848547
Provider Name (Legal Business Name): KATLIN MAY CICCHETTI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATLIN MAY CORMIER PHARMD

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W NEIDER AVE
COEUR D ALENE ID
83815-9300
US

IV. Provider business mailing address

13198 N TELLURIDE LOOP
HAYDEN ID
83835-3308
US

V. Phone/Fax

Practice location:
  • Phone: 208-765-4410
  • Fax: 208-765-0451
Mailing address:
  • Phone: 509-855-2351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60749814
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7950
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: